AYSTA/ AOSTA/ AMSA

*
*) please circle the category
APPLICATION/NOMINATION FORM (page 1)

Nominee Information

Member State:

Last Name: First Name:

Date of Birth (day/month/year):

Address:

Telephone: Email:

Title:

Institution/Affiliation:

Field of Research:

Date Ph.D. Awarded:

List of Scholarly Publications (Please list below in English):

Please denote which scholarly publications include co-authors from ASEAN member states and Dialogue Partner
countries.

[INSERT PUBLICATIONS HERE – if more space is needed, please attach additional page]

Other Awards, Achievements, Patents, etc. (Please list below in English):

1
Please denote which, if applicable, have a connection to other ASEAN member states and Dialogue Partner
countries.

[INSERT AWARDS/ACHIEVEMENTS HERE – if more space is needed, please attach additional page]

2
APPLICATION/NOMINATION FORM (Page 2)

** For AYSTA and AOSTA → To Be Completed by Applicant’s Supervisor Employer

** For AMSA ➔ To Be Completed by Respective Senior Official in the related ASEAN

Ministries/Related Agencies (but cannot be the ASEAN COST Delegates)

Supervisor/Employer Name:

Country:

Last Name: First Name:

Telephone: Email:

Relation to Candidate (if any):

Title:

Institution/Affiliation:

Supervisor/Employer Signature (AYSTA and AOSTA) (signature)

Respective Senior Official (for AMSA) (signature)